Week 3 - Assessment, MSE, Diagnosis/DSM Flashcards

Question

ASEBA | The six DSM-Oriented scales are?

Answer 1

Affective Problems Anxiety Problems Somatic Problems Attention Deficit/Hyperactivity Problems Oppositional Defiant Problems Conduct Problems

Answer 2

Developed to assess DSM-IV anxiety disorders Child and parent versions; also a pre-school version Assesses six domains of anxiety: 1. generalized anxiety 2. panic/agoraphobia 3. social phobia 4. separation anxiety 5. obsessive compulsive disorder 6. physical injury fears

Answer 3

Child version: 44 items – 38 address symptoms, 6 reflect response bias Parent version: 38 items Preschool version: 28 items Pre-school teacher: 22 items Takes around 10 minutes to complete Rate on a 4-point scale :never (0), sometimes (1), often (2), and always (3), the frequency with which they experience each symptom Good psychometric properties

Answer 4

A template that assists a Clinical Psychologist in the collation and subsequent conceptual organization of clinical information about a client’s emotional and cognitive functioning By systematically basing observations on verbal and non-verbal behavior, the aim is to increase the reliability of the data upon which subsequent diagnoses and case formulation are made Following Daniel & Crider (2003) an MSE collates information about the client’s (i) physical (ii) emotional (iii) cognitive state

Answer 5

Appearance Behaviour Motor Activity

Answer 6

Attitude | Mood and Affect

Answer 7

``` Orientation Attention and Concentration Memory Speech and Language Thought (Form and Content) Insight and Judgement Intelligence and Abstraction ```

Answer 8

Draw attention to the key features that describe the client and frame the presenting problem within a context of who the client is Typically the description will begin with a statement about their age, gender, relationship status, referrer and presenting problem (i.e., the reason for presentation at the service on the particular occasion) E.g., “Gill, a young looking 35-year old, single woman was referred by her medical practitioner who had suggested treatment for obesity that was contributing to hypertension.”

Answer 9

A concise summary of the client’s physical presentation is given to paint a clear mental portrait dress, grooming, facial expression, posture, eye contact, as well as any relevant noteworthy aspects of appearance

Answer 10

May make reference to: - level of consciousness extending from alert through, drowsy, a clouding of consciousness, stupor (lack of reaction to environmental stimuli) and delirium (bewildered, confused, restless, and disoriented), to coma (unconsciousness) - degree of arousal (e.g., hypervigilance to environmental cues and hyperarousal such as observed in anxious and manic states) - mannerisms (e.g., tics and compulsions).

Answer 11

Describe both the quality and the types of actions observed: - -reduction in the level of movement (psychomotor retardation) - -slowed movement (bradykinesia) - -decreased movement (hypokinesia) - -absence of movement (akinesia) - -increases in the overall level of movement (psychomotor agitation) - -tremor

Answer 12

Identifiers may be open, friendly, cooperative, willing, and responsive on one hand or closed, guarded, hostile, suspicious, passive on the other Describe attentiveness, responses to questions, expression, posture, eye contact, tone of voice

Answer 13

Affect (an external expression of an emotional state) is potentially observable Mood (internal emotional experience that influences perception of the world and behavioural responses) requires clinician to depend on the client’s introspections

Answer 14

Descriptors: - euthymic (normal non-depressed, reasonably positive mood), - euphoric, - dysphoric, - hostile, - apprehensive, - fearful, - anxious, - suspicious Stability of mood can also be noted, with the alternation between extreme emotional states being referred to as emotional lability Range, intensity, and variability of affect can be variously portrayed: - -restricted (i.e., low intensity or range of emotional expression) - -blunted (i.e., severe declines in range and intensity of emotional range and expression) - -flat (i.e., absence of emotional expression,) - -exaggerated (i.e., an overly strong emotional reaction) Appropriateness (expression incongruent with verbal descriptions and behavior) -General responsiveness of the client.

Answer 15

A person’s orientation refers to their awareness of time, place, and person Orientation for TIME refers to a client’s ability to indicate the current day and date (with acceptance of an error of a couple of days) Orientation for PLACE can be assessed by why they have presented. Behavior should also be consistent with that expected in the setting in which they have arrived Orientation for PERSON refers to the ability to know who you are, which can be assessed by asking the client their name and about the names of family members or friends.

Answer 16

Working memory (Baddeley, 1986; 1990) is the term now used in psychology to refer to the constructs called attention and concentration The aim is to describe the extent to which a client is able to focus their cognitive processes upon a given target and not be distracted by non-target stimuli --Digit span (the ability to recall in forward or reverse order increasingly long series of numbers presented at a rate of one per second) is a common way to assess these working memory functions, and normal individuals will recall around 6-8 numbers in a digits forward and 5-6 in digits backwards “Serial sevens” in which seven is sequentially subtracted from 100. Typically people will make only a couple of errors in 14 trials.

Answer 17

A MSE will typically assess memory using the categories of short and long-term memory Categories do not map neatly onto models of memory in recent cognitive psychology (Andrade, 2001) Aim of the MSE is to provide a concise description of a person’s behavior and screen them in a manner that can guide further assessment. Recent or short-term memory - -ask about a recent topical event or who the President or Prime Minister is - -listen to three words, repeat them, and then recall them some time later in the interview. Most people will usually report 2-3 words after a 20-minute interval Visual short-term memory --copy and then reproduce from memory complex geometrical figures (such as those in the Rey Complex Figure task?) --Long-term memory can be assessed by asking about childhood events.

Answer 18

Form (or process) of thought is evident in terms of the - (i) quantity and speed of thought production - (ii) the continuity of ideas: (circumstantiality or tangentiality) or may perseverate with the same idea, word, or phrase They may show a loosening of associations (where the logical connections between thoughts are esoteric (intended for or likely to be understood by only a small number of people with a specialized knowledge or interest)or bizarre) Flight of ideas (very rapid thinking) Blocking (person's speech is suddenly interrupted by silences); circumstantiality (focus of a conversation drifts, but often comes back to the point) Tangentiality (oblique, digressive, or irrelevant replies to questions)

Answer 19

Content of thought -Delusions are profound disturbances in thought content in which the client continues to hold to a false belief despite objective contradictory evidence, despite other members of their culture not sharing the same belief - vary on dimensions of plausibility and systematization - -persecutory (others are deliberately trying to wrong, harm, or conspire against another) - -grandiose (an exaggerated sense of one’s own importance, power, or significance) - -somatic (physical sensations or medical problems) - -reference (belief that otherwise innocuous events or actions refer specifically to the individual) - -control, influence and passivity (belief that thoughts, feelings, impulses, and actions are controlled by an external agency or force) - -nihilistic (belief that self or part of self, others, or the world does not exist) - -jealous (unreasonable belief that a partner is unfaithful) - -religious (false belief that the person has a special link with God) More frequent issues: - phobias (excessive and irrational fears) - obsessions (repetitive, and intrusive thoughts, images, or impulses) - preoccupations (e.g., with illness or symptoms).

Answer 20

Hallucinations: perceptual disturbance in which people have an internally generated sensory experience, so that they hear, see (visual), feel (tactile), taste (gustatory), or smell (olfactory) something that is not present or detectible by others The most frequent hallucinations are auditory and typically involve hearing voices, calling, commanding, commenting, insulting, or criticizing Hallucinations can also occur when falling asleep (hypnogogic) or when awaking (hypnopompic). Other perceptual disturbances include: - -external world is unreal, different, or unfamiliar (derealization) - -self is different or unreal in that the individual may feel unreal, that the body is distorted or being perceived from a distance (depersonalization) Perceptions can also be dulled or heightened

Answer 21

Insight is a dimension that describes the extent to which clients are aware that they have a problem - -A strong lack of insight can be an important indicator of unwillingness to accept treatment - -Insight refers also to an awareness of the nature and extent of the problem, the effects of their problem on others, and how it is a departure from normal Judgment: The ability to make sound decisions can be compromised for a number of reasons --ascertain if poor decisions are the result of problems in the cognitive processes involved in the decision making process, motivational issues, or failures to execute a planned course of action.

Answer 22

Described in terms of: - Rate (e.g., slow, rapid) - Intonation (e.g., monotonous) - Spontaneity - Articulation - Volume - Quantity of information conveyed: - -----mutism (i.e., absence of speech) - -----poverty of speech (i.e., reduced spontaneous speech) - ----pressured speech (i.e., rapid speech that is hard to interrupt and understand) -Language includes reading, writing, and comprehension. - Disturbances such as aphasia (impairment of language, affecting the production or comprehension of speech and the ability to read or write) - --Non-fluent (where speech is slow, faltering, or effortful) or fluent - --Fluent aphasia speech that is normal in terms of its form (rhythm, quantity, and intonation), but is a meaningless perhaps including novel words (i.e., neologisms).

Answer 23

A general indication of intelligence is said to be gained from the amount of schooling a person has had (?!): - -failure to complete high school indicating below average - --completion of high school indicating average intelligence - ----college or university education indicating high intelligence Abstraction is the ability to recognize and comprehend abstract relationships – to extract common characteristics from a group of objects (e.g., in what way are an apple/banana or music/sculpture alike?), interpretation (e.g., explaining a proverb such as a stitch in time saves nine).

Answer 24

Mini Mental State Exam (Folstein, et al., 1975) - -11-items, measure orientation, registration, attention & calculation, recall, language, and praxis - -Scores ranges from 0-30 and lower scores indicate greater impairment - -less sensitive for cases with milder impairment - -scores influenced by educational level Cognitive Capacity Screening Examination (CCSE; Jacobs, et al., 1977) --30-item screener to detect diffuse organic disorders; more appropriate for cognitively intact individuals High Sensitivity Cognitive Screen (HSCS; Faust & Fogel, 1989) --15-item scale; valid and reliable indicator of cognitive impairment Mental Status Questionnaire (MSQ; Kahn, et al., 1960) --10-item scale that shares the same weaknesses as MMSE but omits some key domains of function (e.g., retention and registration) Short Portable Mental Status Questionnaire (SPMSQ; Pfeiffer, 1975) --10-item scale for community or institutional residents; reliable indicator of organicity.

Answer 25

Formal MSE – not necessarily appropriate for all clients in all settings Depends on level of psychopathology Depends on requirements of setting

Answer 26

Communication – lets us talk about a particular group of issues Research – we’ve talked about the good and bad of this before – we can look at ‘when we have an individual with these particular problems…we know x, y, and z about them – because it has been shown to be so’ It makes research easier (NOT categorising people – we are classifying disorders that people have!) Treatment – helps to guide treatment If we know that this person has Depression – then we have some idea of what best practice is for that disorder and where to go with it

Answer 27

Stigma, labelling: - -Heterogeneity - -Public perceptions - -Important implications - -Self-fulfilling prophecy Categorical approach - -Heterogeneity - -Dimensional?

Answer 28

People assume that all people with a particular ‘label’ are the same – but very heterogeneous – even within the category – have to have 7 of the 9 etc Worst with the public – e.g., ‘schizpophrenic’ – thanks to movies and ACA – people seem to think that they’re all knife-wielding maniacs reading to kill you as look at you – completely untrue – a very SMALL subsample of that population Another point – try not to used ‘shizophrenic’ – a person with schizphrenia – the person has a disorder, they are NOT their label Once a label is given, it’s hard to get rid of Self-fulfilling prophecy – I’m this, and therefore I’ll always be this, and really then they always will – behave in accordance with their label or use it as an excuse – can get in the way of treatment

Answer 29

First major revision in 20 years Has taken 6 years Have tried to make it tie in better with ICD-10 (and the future ICD-11) Trying to help psychiatry (and presumably psychology) ‘better resemble medicine’… Emphasise development, gender and culture on the presentation of disorders

Answer 30

Introduced 2013 --947 pages; ? Diagnoses Change in number system which allows for ‘point upgrades’ (cynically, for more sales as it cost APA US$25 million to produce) Many changes in diagnoses and their criteria & organisation of diagnoses Removal of multi-axial system (explained later)

Answer 31

``` Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders ``` Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders Other Mental Disorders Medication-Induced Movement Disorders and Other Adverse Effects of Medication Other Conditions That May Be a Focus of Clinical Attention

Answer 32

A mental disorder is a syndrome characterized by Clinically Significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are Usually Associated with significant distress or disability in social, occupational, or other important activities. An Expectable or Culturally Approved response to a common stressor or loss, such as the death of a loved one, is NOT a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders Unless the deviance or conflict results from a dysfunction in the individual, as described above.’

Answer 33

Medical model Descriptive Guidelines - not cookbook Clinical judgement = important Does not require knowledge of its aetiology Need to be mindful of cultural issues Need more than diagnosis to develop treatment plan

Answer 34

Codes – subtypes – specifiers Subtypes are mutually exclusive Specifiers are not mutually exclusive (e.g., PTSD - chronic with delayed onset) ---Under DSM-5 some disorders and subtypes share the same code (e.g., 309.81 = PTSD) to make sure it is consistent with ICD-10 (upon which the US and Aus government and insurance companies rely for billing and funding, of course)

Answer 35

Subtype: “Specify whether”—only choose one; Specifier: “Specify if”—pick as many as apply; Severity: “Specify current severity”—choose the most accurate level of symptomology.

Answer 36

The first diagnosis is called the principal diagnosis. In an inpatient setting, this would be the most salient factor that resulted in the admission (APA, 2013). In an outpatient environment, this would be the reason for the visit or the main focus of treatment. The secondary and tertiary diagnoses should be listed in order of need for clinical attention.

Answer 37

Provisional diagnosis: think criteria will be met but as yet not enough information Not otherwise specified: Four situations: --Conforms to diagnostic class but does not meet criteria of subtypes (atypical/mixed presentation) --Conforms to symptom pattern not in DSM (clinically significant distress/impairment) --Uncertainty about aetiology (medical?) --Insufficient information available (emergency/contradictory information)

Answer 38

Discontinued 5-Axis system No more problems of “Axis 2” or GAF? NOS replaced by "Other Specified” or “Unspecified” “Another Medical Condition" instead of “General Medical Condition” Axis 4 gone - -might use V (or Z in ICD 10) codes: - ---These are designed for occasions when circumstances other than a disease or injury result in an encounter or are recorded by providers as problems or factors that influence care. These codes represent the reason why the psych – patient encounter exists. It may be more for financial coding reasons used by insurance companies and health departments, not a measure of psychosocial / environmental stressors! Axis 5 gone - -might use WHODAS. (World Health Org Disability Assessment Schedule) - -List multiple diagnoses in order of attention or concern

Answer 39

How to differentiate one disorder from others with similar presenting characteristics A process of systematically considering & ruling out other possibilities Appendix A – decision trees for differential diagnosis Read Differential Diagnosis section for disorder – consider all possibilities Especially consider – substance-related disorders, medical conditions, adjustment disorder, clinical significance, rule out factitious disorder/malingering